Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

Wednesday, January 30, 2008

Conversations with an anon (hopefully a future named and useful contributer to our humble blog) made me wonder.

Years ago, when we first started seeing MRSA, we went through tons of positive cultures. By the time the cultures returned, the patients were better. So, many of us decided to stop spending $50 bucks a pop to diagnose something we already suspected and had treated. We were wasting a fortune on useless cultures.

So, here's my current practice. If it looks and smells like MRSA, I don't culture UNLESS it's a diabetic, chemo pt, child, septic pt, located over a joint, or there's something else complex or unusual about it. If it smells anaerobic or looks different, I go ahead and pop the culture. In this manner, I probably only culture about 20% of the abscesses I drain.

On a related topic, where I worked before, we almost never put these patients on antibiotics after I&D (unless there was surrounding cellulitis or another complicating factor). When we saw them back, they were doing fine.

At my current hospital, Bactrim and Clinda are standards of care after I&D of the abscess. So, I play along, and I can't tell that there's any better or worse outcomes than in the location where we didn't use antibiotics.

As for Bactroban Ointment, I know some folks who use it for everyone, and others who only use it for patients with recurrent infections, or family/workplace outbreaks.

Here are my questions:

What do YOU do (no "right" answers here): - Do you culture ALL of your I&D's? - Do you put them all on antibiotics? - When do you use Bactroban nasal?

Finally, Do you follow these patients in the ED (like we do), or do you have a place to send them for follow up?

27 comments:

when i was working with some ER docs, we would do plenty of I&D's but would rarely send cultures...one doc would prescribe abx for almost all the patients, whereas another saved them for those that 'looked' like they needed it. we tell them they can follow up with us or their PCP, it's up to them

I rarely culture any abscesses, maybe 1 in 20, and that's usually in a patient I intend to admit with a complicated infection.

I do put almost 100% of them on antibiotics, but only in the CYA sense. I don't think it's necessary most of the time, but like you, I do it anyway because everybody else does. I also pack most of my abscesses.

I like to follow them up myself in two days if I happen to be working...I'll tell them to come back when my shift starts. Otherwise someone else in our group will see them. We never send them back to the PCP for followup, but I do occasionally refer selected cases to a surgeon.

The ER that I work in seems to culture all wounds. Generally the doctor will place them on an antibiotic. The culture results get sent directly to the patient's PCP who we tell them to follow up with in a few days.

Rarely do we see the patient back in the ER unless he doesn't want to make an appointment with his PCP or he doesn't have one. We try to discourage repeat visits to the ER for follow up.

Oh, by the way. I think you sent Anonymous Ass over to my place. He's so witty.........NOT

Gah. I love blood and guts as much as the next non-doctory type, but that video was almost too much for me to handle, (and I translated for docs in a third world clinic, so I'm not overly squeamish. We saw some nasty stuff there.).

If I can get something out of it, I culture it. These days with all the freakin' MRSA, I empirically start bactrim and change it if I need to. Unfortunately, I haven't had to change it much lately. If I'm doing this in the outpatient setting, I have them follow up in a week's time (sooner if it's looking nastier). If I'm doing this in the ER, I have them follow up with their PCP.

There's been a lot of debate betwixt the ID docs and non-ID docs in my department as to what to do for an abscess and almost everyone is doing the drain and Bactrim song and dance.

I only use Bactroban in the nose if this is a patient's second time or more with a CA-MRSA infection. One of our ID docs has a handout on how to eradicate it, which includes nasal Bactroban. I haven't given it to enough of my patients to see if it works yet.

I'm almost afraid to ask if you would mind elaborating. If I have an open lesion, should I be sniffing it? What is it supposed to smell like? More to the point, what is it *not* supposed to smell like?

As you can tell, I do not have a clinical background... thank god. Some things are better left to the experts. :)

I almost never culture abscesses. I only put them on antibiotics if I suspect MRSA (report of spider bite, multiple abscesses, H/O MRSA abscesses, etc). Almost never use Bactroban, but mostly because I forget to think about it.

Good question though--I'm not sure we're doing any good. We don't even know if Bactrim/Clinda works in vivo, not even considering the question of if you need to ever treat I&D'ed abscesses. Did we ever really have to MSSA?

Good blog, by the way. I just started my own and linked yours. Hope you don't mind. :)

Thanks for the input. Sounds like most don't see a need for a culture in these patients and there's a lot of variability in other practices.

A few years ago, one of my partners got called before the Med Exec committee because he didn't culture one of these. The patient got worse and ended up in the hospital and of course, the admitting doc was held in complete vapor-lock because there wasn't a culture sent.

To the anon question, I may need some help from Etotheipi to describe the anaerobic pussy (pus-sy) smell..........

You know when you walk out in the back yard and take a whiff....and you're sure something is dead somewhere? You search around and find a dead squirrel or mouse? That's as close as I can come to describing it.

take the chuck taylors you wore for a week straight at summer camp without changing your socks, pee in them, put a dog turd in them and one spoonfull of peanutbutter, tie the shoe under rosie o'donnell's armpit while death marching her on a treadmill for ten hours, let shoe bake in sun for two weeks = there you have it, the smell that comes out of an anaerobic abscess.

I once saw a pregnant EMT barf all over the ER floor...she caught a wiff of an abcess. I was giving the doc heck, "man, why didn't you let me drain it, blah blah blah" he said he'd drained it that morning, before I was at work...this was around dinner time...I would have hated (and loved...its a love hate relationship, :P) to be there when he drained it!

In FP residency we were told to use "purulent" to describe a lesion which contained pus, thereby avoiding the pitfall of attempting to use "pus" as an adjective. Because adding "y" to some things may end up being more descriptive than you planned.

I'm with everyone else. I rarely culture (unless I'm going to admit them or they've got underlying complicating problems). I usually treat with Bactrim and Doxy and we have them follow up with us (or PCP if they can get in) in 2 days for packing removal and wound check. I use Bactroban occasionally in recurrent cases.

I think I wouldn't culture in healthy adult but I never have the chance because all mine are children, pregnant, diabetic, HIV+ or all the above! Also can't rely on them to do twice daily clean dressing changes, much less apply bactroban 4 x daily.

ER Nurse in CA here- I don't see too many wound cultures sent, but Nurse K is right, everyone and their brothers get blood cultures. As far as abx- some doctors give 'em religiously, some rarely. Bactrim and Rifampin seem to be the most common. And it's purulent drainage!! pus-y..*snort* Speaking of funny charting.... I was once charting on a pt that came in drunk and non-responsive, but was beginning to wake up and I wrote "Pt arousable to manual stimulation" (Meaning if I gave her a sternal rub, she woke up and swore at me) Heh Heh Heh.

Thanks for all comments on this topic. Blood cultures on sick folks will likely continue to be a thorn in everyone's side for years to come. It doesn't matter how many studies show their uselessness, the consultants just "vapor-lock" without them. I hate to admit it, but I just gave in and order them.

Thanks for all of the "pussy" corrections. I am aware of the purulent word....I know that sarcasm doesn't come across well in text, but you can assume I'm joking or being sarcastic most all of the time!